Commentary on political happenings around the nation and locally in Milwaukee, WI.

Wednesday, January 31, 2007

Doyle's Universal Coverage Plan: That's It?

I liked Governor Doyle's health care plan more before it was framed as a universal health care plan.

Before, I saw the plan as an important temporary step in the movement for universal coverage, and a step that made political sense since the Assembly is still held by the GOP. Striving to cover all Wisconsin children through BadgerCare Plus was a bare minimum reform that, in my view, was going to tide the state over until broader reforms were politically tenable.

But now that Doyle is touting his ideas as a universal coverage plan, I can't help but wonder: That's it?

To be sure, 98 percent coverage -- if accurate -- is a great number (**SEE LATE UPDATE**). No complaints there. But the way Doyle plans to get there, which is to essentially work through the existing mess of a system we have, is troubling.

For starters, the plan to expand Medicaid to cover workers up to 200 percent of the poverty level is just expanding a system that reimburses providers at horribly low rates and, subsequently, shifts the leftover cost of that care onto other payers in the system.

Plus, studies have shown that Medicaid patients often have almost as difficult of a time finding non-emergency health care as the uninsured, probably because providers don't want to deal with the low reimbursement rates. This is the sign of a broken system, not one that should be relied upon for universal coverage.

(Side-Note: I realize BadgerCare is a part of the Medicaid system and therefore contributes to the problem of low reimbursement rates, but the moral imperative of ensuring Wisconsin children have the health care they need now makes the admittedly temporary fix of expanding BadgerCare a worthwhile endeavor.)

And Doyle's plan also does little to nothing to deal with the other problem of our health care system: cost. While coverage should always be a concern, cost should not be forgotten (**SEE UPDATE**).

There is tremendous administrative waste in our current system, and aside from some enrollment efficiencies realized through BadgerCare Plus (again, a portion of the plan I support), there is nothing in Doyle's plan that would tackle the issue of overhead.

And increasing costs also bring about the issue of under-insurance, which is quickly becoming almost as significant of a problem as no insurance. As health care costs rise, employers are forced to shift more costs onto employees, which either encourages or forces people to take lower and lower levels of coverage. Then when ailments do arise, unpaid medical bills are the result. And unless people can scrounge up the money or put it on their credit cards (which, needless to say, causes other issues), that unpaid cost -- like the low Medicaid reimbursements -- also gets passed on to other payers in the system.

The fact is our current health care system is full of wicked cycles like that -- the cost of the uninsured is an important one, but it's still just one -- and the only way to address all of them is fundamental health care reform. In other words, the entire system needs to change.

But perhaps my biggest concern with Doyle's plan -- now that it's being framed as a universal health care plan -- is that it will become a political straw man for universal coverage in the state. And, if enacted, I'm afraid people will see that the broken health care system around them hasn't really changed, and they'll wonder about universal coverage, "This is it?"

UPDATE: Here's an interesting conversation taking place at the American Prospect website on what components are necessary for health care reform. In the section penned by Jonathan Cohn from The New Republic, a question arises over whether coverage and cost can be tackled simultaneously in any reform measure.

Cohn writes: "The political realist in me, however, says that trying to solve both the cost and access problems simultaneously is begging for trouble. (Just ask the architects of the Clinton health care plan.) In fact, the only way to enact universal health care may be to 'buy off' various interest groups with terms more favorable to them -- terms that inflate the price."

Interesting thought, but the political realist in me thinks that any reform that deals with coverage and not cost is set-up for failure from the start. It will fail on a policy level because as costs mount, the existing system will continue to deal with it by stripping more and more people of basic coverage levels, which, in turn, replaces the problem of the uninsured with the problem of the underinsured. And it will fail on a PR level because as costs mount, critics of reform will use those costs as evidence for why universal care is just too expensive -- even for the richest nation in the world.

LATE UPDATE: Wiggy makes a good point in the comments. Considering Wisconsin already has an insured rate of 95 percent (although the DHFS has estimated another 5 percent go without coverage for a portion of each year), the governor's plan amounts to about a 3 percent increase in the insurance rate. BadgerCare Plus would account for two of those points, and the Medicaid expansion would account for the third point.

Without a doubt, Doyle's plan is significant for the 174,000 who would get access to coverage under it, but when we talk about "universal coverage" in Wisconsin, the thing is we're already pretty close to it -- certainly closer than most states and the country as a whole (the national uninsured rate is about 16 percent).

In that sense, marginal reforms like those offered by the governor are really all that's needed to push us to the brink of covering every Wisconsinite.

But what I was trying to express in the post is that while the literal meaning of "universal coverage" is covering everyone, in many ways that phrase has become shorthand for fundamental health care reform, which Doyle's plan is not.

And Wisconsin, due to its high insured rate to start, just so happens to be in a unique position among states to make its reform truly fundamental by also aiming it at the issue of cost, specifically how its spiraling effect is driving more and more people into cases of underinsurance and backing an increasing number of employers -- public and private -- into a financial wall.

But if people are lulled into thinking Doyle's plan is the only reform that's needed, which is what may happen with its framing as "universal," then it may actually have the unintended effect of setting back truly fundamental reform.

The number of completely uninsured residents in Wisconsin is estimated at 272,000, which is about 5 percent of the population, as you note (although the DHFS has estimated that another 5 percent go without coverage for some portion of each year). The BadgerCare Plus expansion would cover an estimated 113,000 people and expanding Medicaid would cover another 61,000, dropping the completely uninsured number in the state to about 98,000, or 2 percent of the state population (I don't know what Doyle's plan does, if anything, to the 5 percent who go for only portions of the year without coverage).

I'm not sure what you mean by "too much" (I actually think Doyle's plans are fairly marginal), but, unless you're one of those 174,000 who'd be getting access to coverage, I agree the numbers don't seem all that significant on the whole (at least compared to other parts of the country, or the country as a whole). That's why it's my feeling that the under-insurance problem is at least as much of a public policy issue in Wisconsin as the uninsured problem. That may not be true for other states, such as Florida, where the uninsured rate is 18 percent of the population, or the country as a whole where the rate is about 16 percent.